Health inspection·November 9, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of wheelchair while sitting in front lobby. This failure contributed to Resident 1 sustaining an open injury to forehead and being set out to hospital for further evaluation. Findings: During review of Residents 1's admission Record (general demographics), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses to include: NON-ST elevation myocardial infarction (partial blockage of coronary arteries, reducing blood flow to heart), muscle weakness, difficulty in walking, diabetes type II (body does not produce enough insulin, hypertension (high blood pressure). During concurrent interview and record review of Resident 1's Medical Record with the Director of Nursing (DON) and Minimum Data Set (MDS) nurse, reviewed and verified the following: 1. Progress Note dated July 31, 2023, at 20:28: Fall Risk place near nurse station. 2. Careplan Fall risk for falls r/t .Goal: Will not sustain serious injury through the review date. initiated July 31, 2023, on admission, Revision August 21, 2023. 3. Change in Condition (COC) fall August 02, 2023, Resident found on left side of bed sitting on his bottom, pr resident he was attempting to use commode (No update on careplan for fall 08/01/23). 4. PROGRESS NOTE dated August 05, 2023, at 05:52 .S/P Fall .tab alarm placed on resident .resident still attempts to get out of bed. 5. COC Fall August 18, 2023, .Resident had a fall from wheelchair attempting to transfer with no assistance and was noted with hematoma and skin tear to forehead. No changes in mental status from baseline. 6. Progress Note dated August 18, 2023, at 11:30 .Notified by staff resident had a fall .responded to front lobby and noted resident in lying on his right side with head and the foot of chair in the lobby and bathroom door .bump and skin tear with flap to right side of forehead, scant bleeding, Page 1 of 3 056372 056372 11/09/2023 Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dietary staff witnessed resident fall .staff not close enough to resident to assist him .NP notified order to send to ER for evaluation due to bump on head and being on blood thinner. 7. Physical Therapy notes dated August 01, 2023 fall risk .exhibits weakness in Both Lower extremity muscles, decrease standing balance and decreased safety awareness with compromises residents safe discharge home . During an interview on October 24, 2023, at 11:14 AM, with the Occupational Therapist (OT), OT stated, Resident 1 was my patient in the morning, that morning he was confused more as usual, I reported it to the nurse. I took him to therapy room. The other therapist placed him upfront. Sometimes we do place residents in front lobby or outside, but an aid goes with them. I'm not sure who he was with in the front lobby. For my part due to his history of fall risk, I would have left him in the therapy room. I don't remember if he had tab alarm, we usually have then for fall risk, and low position beds. During an interview on November 09, 2023, at 1:03 PM, with the Physical Therapist Assistant (PTA), PT stated, Resident 1 wasn't as responsive that day, so I put him in the hallway meanwhile I was in with the other resident. I check up on him if he was ok, he told me he wanted to go outside and I told him he couldn't go outside, so I placed him in front lobby by the window and the bathroom .so he could see outside .the receptionist was up front. He was in wheelchair I locked it and he had an alarm on., He is a fall risk. Yes, did need to be monitored, he is unpredictable, he has dementia, they might try to get up and fall they not self-aware. Somedays he might be stronger other days might be weaker. I don't think receptionist has the credentials to monitor and assess but I feel it was safe and staff is always walking around. It's a very gray area on keeping him safe, because he did not go outside, he was in the front lobby. During an interview on November 09, 2023, at 1:08 PM, with the Receptionist, the Receptionist stated, Resident 1 was in wheelchair and wanted to sit by window to get sunlight. He requested to be there, (PT) put him there. We had an employee sitting upfront also .I walked to the office Human Resources, for 1-2 minutes that's when I heard the fall, that employee was with the resident on the floor. I didn't see the fall I heard the fall. I did not know anything about him being a fall risk or any of his medical history. The therapist did not tell me anything about the resident. I'm not able to assess or monitor any resident in facility. What I can do in my job, I'm looking at what is around me, but it's not in my duties to monitor any resident. During an interview with the Director of Nursing (DON), DON stated (PT) placed Resident 1in front lobby, he wanted to go outside, He is very mobile and can wheel himself while on wheelchair. We had receptionist and the dietary witnessed the fall, he resigned. The receptionist went into side office, she heard the bump noise of the fall, he was not left alone. He did have alarm. I was not here when it happened, I can't say yes or no on the prevention of it happening. He shouldn't have fallen but we can't prevent it, he is here for rehab, as the mobility increases. He was placed in front of nurse station on admission, but then we moved him due to isolation, we did identify fall risk. Could he have fallen at home, yes, we can reduce the injury front the fall. When asked, should the resident have been left upfront? Yes, we did not want to restrain him, and the receptionist was in front office .he was mobile and can wheel himself. It's not the receptionist responsibility but its everyone responsibility to help redirect and they can always call the nurse. I was not made aware this resident was a bit more confused, I was not here that day, nor do I not know if it was told to the nurse. During a review of the facility's policy and procedure titled, Fall Management System, Resident 056372 Page 2 of 3 056372 11/09/2023 Brookside Healthcare Center 105 Terracina Blvd. Redlands, CA 92373

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assessment revised [no date], the policy and procedure indicated, STANDARD: This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision, assistive devices and functional programs as appropriate to prevent accidents. POLICY: It is the policy of this facility to provide each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurs. During a review of the facility's policy and procedure titled, Fall Prevention revised [January 2012, the policy and procedure indicated: It is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury. The care plan or an update to an existing care plan will then be generated as needed. 056372 Page 3 of 3